What are the recommended medications for managing hot flashes?

From the Guidelines

Hormone replacement therapy (HRT) is the most effective option for managing hot flashes, typically using estrogen alone or combined with progesterone for women with an intact uterus, as recommended by the NCCN clinical practice guidelines in oncology 1.

Recommended Medications for Hot Flashes

The following medications are recommended for managing hot flashes:

• Hormone replacement therapy (HRT) with low-dose estrogen patches (0.025-0.05 mg) or oral tablets (0.3-0.625 mg daily)
• Non-hormonal options, such as:
  • Certain antidepressants: venlafaxine (37.5-75 mg daily), paroxetine (7.5-20 mg daily), and escitalopram (10-20 mg daily) 1
  • Anticonvulsants: gabapentin (300-900 mg daily) and pregabalin 1
  • Antihypertensives: clonidine (0.1-0.2 mg daily)

Important Considerations

• Treatment choice depends on symptom severity, medical history, and personal preferences, and should be individualized for each patient
• HRT carries some cardiovascular and breast cancer risks that should be discussed with a healthcare provider 1
• Non-hormonal options may have side effects, such as dry mouth, decreased appetite, fatigue, nausea, constipation, and possible sexual dysfunction 1
• The NCCN Panel recommends alternative therapy if available for women taking tamoxifen and pure SSRIs, such as paroxetine, due to potential interactions 1

From the FDA Drug Label

PREMARIN is used after menopause to: Reduce moderate to severe hot flashes Estrogens are hormones made by a woman's ovaries. The ovaries normally stop making estrogens when a woman is between 45 and 55 years old This drop in body estrogen levels causes the “change of life” or menopause (the end of monthly menstrual periods). Sometimes, both ovaries are removed during an operation before natural menopause takes place. The sudden drop in estrogen levels causes “surgical menopause.” When the estrogen levels begin dropping, some women get very uncomfortable symptoms, such as feelings of warmth in the face, neck, and chest, or sudden strong feelings of heat and sweating (“hot flashes” or “hot flushes”).

The recommended medication for managing hot flashes is estrogens (PO), such as PREMARIN.

• Key benefits: Reduce moderate to severe hot flashes.
• Important considerations: Using estrogen-alone increases the chance of getting cancer of the uterus, and may increase the chances of getting strokes or blood clots 2 2.

From the Research

Recommended Medications for Hot Flashes

The following medications are recommended for managing hot flashes:

• Hormone replacement therapy (HRT) with estrogen, which is the most effective treatment for hot flashes 3
• Non-hormonal pharmacologic treatments, such as:
  • Selective serotonin reuptake inhibitors (SSRIs) like paroxetine, fluoxetine, and venlafaxine, which have been shown to reduce hot flashes by 50-60% 4, 5, 6
  • Gabapentin, which has been found to be effective in reducing hot flashes in some women 4, 5, 6, 7
  • Desvenlafaxine, citalopram, and pregabalin, which have also been tested in randomized placebo-controlled trials and shown to be effective 6

Considerations for Prescribing Medications

When prescribing medications for hot flashes, the following considerations should be taken into account:

• Potential benefits and adverse effects of each treatment option 4
• Contraindications to estrogen-containing treatments, such as a history of breast cancer or high risk of developing breast cancer 5, 6
• Interactions between medications, such as the interaction between fluoxetine and paroxetine and the metabolism of tamoxifen 6
• The need for caution when stopping treatment with SSRIs to prevent a discontinuation syndrome 4